Gait steady. Skin pink over extremeties. Muslces equal in size and shape bilaterally, with the exception of the biceps- right bicep larger in size and more defined in shape than left bicep. No hypotonicity or atrophy noted. Spinal column is midline without deviation. Grip strength rated a 5/5 bilaterally. Full resistance of lower extremities noted 5/5. Full ROM in all joints.
Abdomen
Skin over abdomen is pink. No pulsations visible. Active bowel sounds in all 4 quadrants. Contour is rounded. Faded scar over uterus. Significant loose skin over abdomen, resulting in an apron of skin. No rashes or hygiene issues noted. Inguinal nodes not nonpalpable.
Breast Self-Exam
The information in this guide is adapted from guidelines published by the American Cancer Society in September, 2009, and includes changes from prior instructions for breast self-exam.
First, you should do self-exams at the same time of each monthly cycle, because of normal cyclical changes in breast size and shape. First, you should lie down and place your right arm behind your head. Using the finger pads of your index, middle, and ring fingers of your left hand, use dime-sized circular motions to feel breast tissue. Each area should be examined with three different levels of pressure; light, medium, and firm; to assess the different tissue levels. Move around the breast in an up and down pattern, beginning at the middle of the underarm, moving down, and then going all the way to the middle of the chest bone. All areas in the chest should be felt, from the ribs up to the neck or clavicle. Next, examine the underarm area, by removing the arm from behind your head, so that the arm muscles relax. Repeat the exam on your left breast,...
Press your hands firmly to your hips and look for changes in size, shape, and contour. Any redness, scaliness, or dimpling should also be noted (ACS, Breast, 2009).
Testicular Self-Exam
The information in this guide is adapted from guidelines published by the American Cancer Society in August, 2009.
Testicular self-exams should be conducted during or immediately following a bath or shower, when the skin of the scrotum is relaxed. Hold the penis out of the way and examine each testicle individually. Holding the testicle between your thumbs and fingers of both hands, then roll it gently between the gingers. Note any hard lumps or nodules, and any changes in the size, shape, or consistency of the testes. Normal testes have blood vessels, supporting tissues, sperm-conducting tubes, and epididymis, which can feel like lumps or nodules. Therefore, a man should get a baseline of what is normal for his testicles and perform exams looking for changes from normal (ACS, Testicular, 2009).
References
American Cancer Society. (2009, September 18). How to perform a breast self-exam. Retrieved from the American Cancer Society website: http://www.cancer.org/docroot/CRI/content/CRI_2_6x_How_to_perform_a_breast_self_exam_5.asp
American Cancer Society. (2009, August 3). Can testicular cancer be found early? Retrieved
from the American Cancer Society website:
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_Testicular_Cancer_Be_Found_Early_41.asp?sitearea=
